Is it appropriate to order a Kidneys, Ureters, and Bladder (KUB) radiograph or abdominal ultrasound in a 52-year-old male with a history of Impaired Glucose Tolerance (IGT), Hyperlipidemia (HLD), non-cancerous sigmoid mass, Small Bowel Obstruction (SBO), and status post-exploratory laparotomy with enterotomy and removal of a phytobezoar, presenting with abdominal pain?

From the Guidelines

Given the patient's history of small bowel obstruction (SBO) and current complaint of abdominal pain, it would be most appropriate to order a CT abdomen and pelvis with IV contrast as the initial imaging study, as recommended by the American College of Radiology 1. This approach is supported by the latest guidelines, which suggest that CT abdomen and pelvis with IV contrast is usually appropriate for the initial imaging of a suspected SBO with an acute presentation 1. The patient's history of SBO, previous exploratory laparotomy with removal of a phytobezoar, and current complaint of abdominal pain increase the likelihood of a high-grade or complicated SBO, making CT imaging a crucial diagnostic tool to guide management 1. Some may consider a KUB (kidney, ureter, bladder) X-ray or abdominal ultrasound as initial imaging studies, but the latest evidence suggests that these may not be sufficient for diagnosing or guiding management of SBO, especially in patients with a history of complicated SBO 1. Key considerations in selecting the initial imaging study include the patient's specific symptoms, medical history, and the potential risks and benefits of each imaging modality, with the goal of quickly and accurately diagnosing the cause of abdominal pain and guiding appropriate management 1. In this case, the patient's history of impaired glucose tolerance (IGT) and hyperlipidemia (HLD) may increase his risk for certain conditions, but the primary concern is the potential for recurrent SBO or other complications related to his previous surgery, making CT imaging the most appropriate initial choice 1.

From the Research

Evaluation of Abdominal Pain

Given the patient's history of impaired glucose tolerance (IGT), hyperlipidemia (HLD), non-cancerous sigmoid mass, small bowel obstruction (SBO), and previous exploratory laparotomy with removal of a phytobezoar, the presentation of abdominal pain warrants a thorough evaluation.

Imaging Options

• The patient's symptoms and history suggest the need for imaging to aid in diagnosis.
• According to 2, plain abdominal radiography (KUB) has low sensitivity and accuracy for evaluating acute abdominal pain and specific diseases.
• Ultrasonography (abdominal u/s) is a more appropriate initial imaging choice, especially for right upper quadrant pain or when suspecting conditions like cholelithiasis, urolithiasis, or appendicitis 3.
• Computed tomography (CT) with intravenous contrast may be considered for generalized abdominal pain, left upper quadrant pain, or lower abdominal pain, but it is not the first-line imaging choice in this case.

Considerations

• The patient's history of SBO and previous abdominal surgery increases the risk of complications like bowel obstruction or adhesions, which may require imaging for diagnosis.
• Ultrasonography can be useful in evaluating the hepatobiliary tree and detecting conditions like gallstones or bile duct obstruction 4.
• A systematic approach to evaluating abdominal pain, including a thorough history, physical examination, and laboratory tests, is essential for generating a differential diagnosis and guiding further testing 5, 6.

Decision

Given the patient's complex medical history and presentation of abdominal pain, ordering an abdominal ultrasonography (u/s) would be a more appropriate initial imaging choice than a KUB, as it can provide more useful information for diagnosing potential causes of abdominal pain 3, 4.